A&E Perspective: Experts? Who needs them?

Dr Dan O'Carroll


February 04, 2019

It may be that in years to come the long running fictional cartoon character Homer Simpson will get the recognition he deserves as a great modern-day philosopher, but it's very disappointing to see that the chief executive of the NHS, Simon Stevens appears to be adopting one of Homer's least inspirational quotes. "You tried your best and you failed miserably. The lesson is, never try."


Dr Dan O'Carroll

During the Health and Social Care Committee meeting this week Stevens confirmed that the hospital target of admitting, treating or discharging all A&E patients within 4 hours is to be significantly altered. This has been met with almost universal condemnation from those working in the field of emergency medicine.


History of Targets 

To understand the discontent, it's important to understand the history of the A&E 4-hour target. Prior to the introduction of the target, emergency departments (EDs) across the country were often full of patients waiting an unacceptably long time. I vividly remember several occasions when finishing late in the evening to return the next day and find the same patients waiting, some with admittedly minor ailments, but also those on trolleys waiting for hospital beds to become available. Sometimes these waits would extend to days rather than hours

The target was introduced in 2004 and was initially set at 100%, but this was quickly revised down to 98% to reflect clinical concerns that some patients needed to spend more than 4 hours in the ED. It was further reduced to 95% in 2010 by the coalition government, arguing that 98% was not clinically justified. Unfortunately, since December 2015 the 95% target over England as a whole has been missed.

Perhaps the first problem with the target was that it was considered to be just an A&E target, and, in my opinion, it should have been emphasised to be a 'whole-hospital' target from the outset. The ED is entirely reliant on flow to ensure prompt assessment of the in-coming patients. It being an A&E target meant that sometimes there was a lack of support from other specialties and hospital management.

It was around this time that the failure to meet the target was attracting significant media interest and was seen to be potentially embarrassing to the incumbent government. Multiple organisations were declaring 'black alerts' and major incidents due to dangerously overcrowded EDs. There was some suggestion that trusts were being pressured by NHS England to effectively stop calling major incidents and this prompted a lively debate in parliament.

Victims of Their Own Success

There is no question that EDs have been victims of their own success. The general population's demand for ED services grew considerably, and although the vast majority of that growth has been due to the increased frail elderly population and their rising dependency, there has also been an increase in those with what could be considered minor ailments. The population took advantage of the EDs which were seeing and sorting the patients within 4 hours and understandably many decided that there was no reason to wait 2-3 days (or more) for an appointment with their GP. 

We need to be very clear here, the reason that EDs are often dangerously overcrowded is not down to those patients waiting with their 'minor ailments'. It is usually down to exit block, with patients waiting for beds to become available on the wards. The reduction in bed numbers and the collapse of social care contributing to delays in discharging medically fit patients are the main contributors. These are apparently difficult problems to deal with, and perhaps are unsolvable in the current age of austerity. The cynics amongst us would suggest that modifying the 4-hour target will only seek to hide the extent of the problems.

Fast Track, Slower Track

Under Stevens' new plan, people with more serious conditions such as sepsis or heart trouble will be treated faster but those with minor ailments may have to wait longer. Of course, you could observe that we already have targets for the administration of antibiotics for sepsis within the hour, and call to balloon time for myocardial infarctions. On a practical level, this is already happening on the shop floor, as we have to make the judgement call and rightly prioritise those with time critical problems, usually at the expense of those that can be considered 'minors'. One of the key points to consider here, is that the diagnosis or minor ailment is often only clear after a full clinical assessment. How many of the children with snotty noses and apparent upper respiratory tract infections, and therefore 'minors', will actually be suffering from serious or life-threatening infections?

Condemnation of this announcement has been led by the Royal College of Emergency Medicine (RCEM), Taj Hassan, RCEM President, stating: "In our expert opinion scrapping the 4-hour target will have a near catastrophic impact on patient safety in many emergency departments that are already struggling to deliver safe patient care in a wider system that is failing badly. 

"We will be seeking urgent clarification from NHS England and NHS Improvement on their position and describing the likely unintended consequences of such a poorly thought out strategic policy shift. We will also make our position and concerns clear to the Secretary of State, Matt Hancock.

"Let's be very clear. This is far from being in the best interest of patients and will only serve to bury problems in a health service that will be severely tested by yet another optimistic reconfiguration." 

Perhaps even more damning is the open letter to Mr Stevens from Derek Prentice, the lay group chair, RCEM. In his letter he openly questions who the 'top doctors' that want the target changed are, and states that RCEM does not appear to have been consulted. He bluntly asks, "So Mr Stevens, who are these doctors with such contempt for the patient interest?"

We do not want to go back to the dark days when patients would sometimes die whilst waiting on corridors, although worryingly, it may be too late.

The 4-hour target drove great improvements in emergency care within the UK. Resources were put into the speciality, and improvements were made across the board in the provision of emergency care for all our patients. It seems staggering that proposed significant changes could be made to such an important parameter without discussion with those working in the ED, who see the realities of the challenges on a daily basis. But prominent government ministers have 'previous' with their opinions on 'experts', saying:"People in this country have had enough of experts."


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